Medicare Overview

Medicare is a government health insurance program for people:

• Aged 65 years and older.
• Under age 65 with certain disabilities and you’ve been getting social security disability income (SSDI) for more than 24 months
• Of any age if you have end stage renal disease (ESRD) and need dialysis or a kidney transplant.
• Of any age if you have amyotrophic lateral disease (ALS)

The Medicare parts 

Medicare parts cover different services: 

Part A covers: 

• Inpatient hospital stays 

• Skilled nursing facilities 

• Hospice care 

• Some home health care 

Part B covers: 

• Doctor’s services  
• Preventive services (like screening tests, vaccines, and yearly check-ups) 
• Outpatient care 
• Physical and occupational therapy  
• Some home health care 
• Medical equipment (like wheelchairs and walkers)  

Part D covers: 

• Prescription medicines, including some shots and vaccines.  

You can add a Part D plan to your Medicare A or B plan (known as a stand-alone part D plan) or you can choose a Medicare Advantage Plan (offered by private companies known as Part C) with prescription drug coverage.  

Part C is also called Medicare Advantage. They are bundled plans that include Parts A, B, and usually D.  

Some important things to know about Part C: 

• They are Medicare-approved plans from private insurance companies. 
• You usually must use approved in-network providers. 
• May have lower out-of-pocket costs compared to Original Medicare plans without supplemental coverage. 
• May have some extra benefits that Original Medicare doesn’t cover, like vision, hearing, or dental. 

Medicare supplemental plans 

Medicare Supplement Insurance (also known as Medigap policies) are secondary insurance policies that you can buy from a private insurance company to help pay your share of costs when you are enrolled in original Medicare. You must already have Medicare Parts A and B to be eligible. 

Does the doctor take Medicare and accept assignment? 

Before you schedule any appointments, make sure that the doctor accepts Medicare. Ask if they “accept assignment.”  

When a doctor “accepts assignment,” this means:  

• They agree to charge the price that Medicare has set for a certain service. This is also called the Medicare-approved amount. 
• The Medicare-approved amount is usually lower than what the doctor would charge someone who doesn’t have Medicare.  
• They will usually wait for Medicare to pay for their share before asking for your payment. 
• You usually don’t have to pay a deductible or co-pay for most preventive services.  

Doctors who accept assignment are part of the Medicare network, and they can be found easily through the Medicare website or by calling Medicare’s helpline 1-800-MEDICARE (1-800-633-4227).  

 Non-participating doctors and opt-out doctors don’t accept Medicare assignment.  

If your doctor doesn’t accept assignment for all Medicare-covered services, you often must pay out of pocket, and you can be charged more than Medicare covers. Medicare will pay you back part of the bill for the services they cover. 

Coordination of benefits 

You might have Medicare and another insurance plan (such as from Medicaid, a supplemental plan, your job, a retirement plan, or your spouse’s job). 

Coordination of benefits (COB) makes sure your medical bills are paid correctly, and you don’t pay more than you should. 

A few important things to know about COB: 

• If you have more than one insurance plan, one of them is the primary insurer and the other is the secondary insurer. Medicare is usually the primary insurer.  
• Primary insurance pays first. Then your secondary insurance pays what it covers, and anything left is billed to you.  
• You usually don’t have to do anything for COB to work. Your health care providers should send any claims to both insurers.  
• Your primary and secondary insurance providers will talk to each other directly to sort out payments and make sure things are managed correctly. 
• Make sure your health care team has all information for both insurers so they can bill correctly. This will get you the most coverage possible.  

Medicare Savings Programs 

Medicare Savings Programs (MSPs) give people with limited income financial aid and resources to pay for their Medicare costs.  

There are four main types of MSPs: 

• Qualified Medicare Beneficiary (QMB) Programs help pay premiums, deductibles, and coinsurance costs for Medicare Parts A and B.  
• Specified Low-Income Medicare Beneficiary (SLMB) Programs help pay for Medicare Part B premiums.  
• Qualifying Individual (QI) Programs also help pay for Medicare Part B premiums.  
• Qualified Disabled and Working Individuals (QDWI) Programs help pay Part A premiums for certain people who are disabled and have returned to work. This helps people who lost their Social Security benefits and premium-free Part A benefits because you went back to work.   

There are different requirements for these programs depending on the state you live in. The application goes through your state’s Medicaid office.  

Need more information on Medicare Savings Programs?:  

• Visit the Medicare Savings Programs website.  

• Contact your state’s Medicaid office.